Registration Fornhs Care Records

Applicant’s Name:

RA01 Short Form Part 1

Registration forNHS Care Records

Service applications

Please note:

All applicants must have read and agreed to the conditions detailed in the RA01 Short Form Conditions Version 1.2. If you do not have a copy please request one from your Registration Authority before completing this document. All your personal data is processed in accordance with the Data Protection Act 1998 but it is important that you read the full “Notices to applicants on the collection of personal data” set out in the RA01 Short Form Conditions.

Guidance

This form is made up of the following two parts:

Part 1to be completed by you, the applicant,who requiresaccess to NHS Care Records Service applications;
Part 2 to be completed by your Sponsor & RA. Your Sponsor will probably be your Clinical Manager/Line Manager or Supervisor.

Please complete the following details:

Title (eg Dr, Mr, Mrs etc.): / DrMrMrsMsMiss
First Name: / Donald
Middle Name(s):
Family Name (Surname): / Duck
Preferred Full Name: / Donald Duck
National Insurance Number: / DU12345Y
Date of Birth1: / 01 JANUARY 1950
Post title: / Pharmacist Manager
Occupation: / PharmacistQualified
Registering Organisation Name/Code: / Pills The Chemist Ff123
Site Name2: / Pond Street
Telephone number3: / 0114 1212123
Email address3: /
Previous Registration Details: / Not Applicable

Key1. Only captured for the purposes of e-GIF level 3 compliance

2. The name of the site where the applicant usually works at the time of registration

3. Either NHS email address or mobile number required to utilise Self service Centre functionality e.g. Self Unlock. Additionally required for all Registration Authority Managers, Agents and Sponsors

Applicant’s details and declaration

I have read and agree to be bound by the terms and conditions stated in the RA01 Short FormConditions version 1.2 or later:

Applicant’s signature:______

Date (dd/mm/yyyy):

Applicant’s Name:

RA01 Short Form - Part 2 Sponsor use only

Sponsor’s declaration

I confirm that the Applicant specified in Part 1should be issued a Smartcard.

Sponsor’s signature: ______

Sponsor confirmation of identity declaration

NOTE: this section should only be signed in the presence of an RA Manager or Agent

(The applicant will, additionally, be required to produce two forms of acceptable non-photographic proof of personal identification and two confirmation of address documents).

I confirm that the Applicantdoes not have any acceptable Photographic Identity Documents; I have known the individual for more than three years and I confirm the identity of this applicant.

Sponsor’s signature: ______

RA use only

Registering Organisation Name
Sponsor / RA Agent/Manager
Name
Smartcard UUID
Date completed
Sponsor present / Yes/*
No* / Passport, Photocard Driving Licence, or Birth cert. no.
Sponsor confirms identity?4 / Yes/*
No* / Confirmation of address seen? / Yes/*
No*
Signed statement and signed passport photo seen? / Yes/*
No*
Issued Smartcard UUID number:

4. Where sponsor confirms identity then 2 forms of acceptable non-photographic proof of personal identification and two confirmation of address documents must be seen by the RA

*Delete where applicable